Medicaid expansion states: Key takeaways
- 37 states and DC have accepted federal funding to expand Medicaid under the ACA. Missouri voters approved Medicaid expansion that was slated to take effect in mid-2021, but implementation has been suspended after GOP lawmakers refused to provide funding.
- Maine approved a ballot initiative in 2017 to expand Medicaid, which took effect in 2019. Utah, Idaho, and Nebraska approved expansion initiatives on their 2018 ballots. Voters in Missouri and Oklahoma passed expansion initiatives in 2020, although Missouri’s has been delayed by GOP lawmakers.
- In 2018, Virginia lawmakers approved Medicaid expansion, which took effect in January 2019.
- Twelve states have received federal approval for Medicaid work requirements, although none are in effect as of 2021, after being overturned or suspended. And the Biden administration has notified states that work requirements will no longer be approved.
- Medicaid and the COVID pandemic: Additional federal funding depends on a state not disenrolling members, but new rules allow for cuts to optional coverage and other benefit changes.
- Some states are attempting to change Medicaid by implementing lifetime caps on coverage, or by adjusting eligibility requirements.
- A handful of states have been exploring Medicaid buy-in programs.
- Thirteen states have yet to take the ACA’s Medicaid expansion. It was 19 as of mid-2018, but Maine and Virginia expanded coverage as of 2019; Utah, Idaho and Nebraska expanded coverage in 2020; and Oklahoma is expanding coverage in 2021.
- Michigan, New Hampshire, Indiana, Pennsylvania, Alaska, Montana, and Louisiana expanded their Medicaid programs after January 2014, but before the end of 2016. So 13 states have expanded Medicaid starting sometime after the start of 2014.
- The 13 states that haven’t expanded coverage are missing out on hundreds of billions of dollars in federal funding if they continue to reject expansion.
- Public support for Medicaid expansion is strong, with 56% of the public in favor of expansion even in deep-red Wyoming.
(Note that this page is focused on Medicaid for people under age 65. For more information about how Medicaid provides assistance to people age 65 and older with limited financial means, choose a state on this map.)
When the Affordable Care Act was enacted in 2010, Medicaid expansion was a cornerstone of lawmakers’ efforts to expand realistic access to healthcare to as many people as possible. The idea was that everyone with household incomes up to 133% of poverty (138% with the 5% income disregard) would be able to enroll in Medicaid starting in 2014. But the Supreme Court later ruled that the expansion of Medicaid eligibility would be optional for states (ie, they wouldn’t lose their federal Medicaid funding if they didn’t expand eligibility), and a quarter of the states have not expanded Medicaid as of 2013.
The American Rescue Plan, enacted in March 2021, provides these holdout states with additional federal funding if they choose to expand Medicaid, although Oklahoma is thus far the only state taking advantage of this — and their Medicaid expansion was already slated to take effect in the summer of 2021, due to a voter-approved ballot measure that passed in 2020.
Since 2010, the number of states that have accepted ACA’s Medicaid expansion has steadily grown – from just a handful by 2012 to 37 states and DC as of mid-2021. Oklahoma is the latest addition to the Medicaid expansion list — with enrollment starting in June 2021 and coverage effective as of July 2021 — after voters in the state approved a Medicaid expansion ballot measure in 2020.
Missouri voters approved a similar measure and it was slated to take effect in mid-2021 as well, but GOP lawmakers in the state refused to allocate funding, and the implementation has been suspended. A court hearing over Missouri’s Medicaid expansion battle is scheduled for June 2021. If the judge rules quickly and in favor of the ballot measure being implemented, it’s possible that Medicaid expansion could still take effect in Missouri as of July 2021, as originally scheduled.
Georgia has also been planning a partial expansion of Medicaid slated to take effect in mid-2021. The proposal was approved by CMS in October 2020, although CMS declined to provide full Medicaid expansion funding, given that Georgia is only partially expanding Medicaid. (A similar partial expansion — with a request for full Medicaid expansion funding — was proposed by Utah in 2019 and rejected by the federal government, with Utah later agreeing to full expansion of Medicaid; CMS has maintained a clear policy, under both the Obama and Trump administrations, of only providing the enhanced federal funding if a state fully expands Medicaid).
Georgia’s partial Medicaid expansion includes a work requirement, and CMS (under the new Biden administration) notified Georgia in February 2021 that the work requirement approval was being reconsidered. Georgia officials responded in March with a letter explaining why they believe the work requirement is an essential part of their plan to partially expand Medicaid, but the situation is still up in the air as of the spring of 2021.
At the same time, there are a host of other Medicaid-related developments in the works across the country – both in expansion and non-expansion states – that could affect eligibility for and access to Medicaid benefits. Some states favor changes that would put increased limits on Medicaid eligibility – such as work requirements and lifetime caps – while other states have considered legislation that would give currently ineligible residents a chance to buy-in.
Suffice it to say, there’s plenty of activity to monitor at the state level. You can click on a state on this map to see current Medicaid-related legislation:
Medicaid expansion with a ballot initiative
In Maine, Utah, Idaho, Nebraska, and Oklahoma, Medicaid expansion came about as a result of ballot initiatives passed by voters. Voters in Missouri passed a similar ballot measure in 2020, but GOP lawmakers in the state have delayed implementation by refusing to fund the state’s portion of the cost. A lawsuit has been filed and the trial is scheduled for June 2021.
So far, Medicaid expansion ballot initiatives have passed in 100% of the states that have had them on the ballot (Montana voters did not approve a 2018 measure that would have provided ongoing funding for the state’s Medicaid expansion — which was already in effect — but this did not affect the state’s Medicaid expansion, which continues to be available to eligible residents).
In early 2021, Medicaid expansion advocates in Florida, Mississippi, and South Dakota were working towards possible expansion ballot measures for the 2022 election (this involves getting approval from the Secretary of State and obtaining enough signatures from voters to get the measure on the ballot).
Legislation to expand Medicaid
Lawmakers in the states that haven’t expanded Medicaid have continued to introduce legislation each year in an effort to expand coverage. In 2018, Virginia lawmakers passed a budget that includes Medicaid expansion, with coverage that took effect in January 2019. By June 2021, more than 555,000 people had gained coverage in Virginia under Medicaid expansion (including a significant number who became eligible for Medicaid due to a job/income loss stemming from the COVID pandemic).
Georgia enacted legislation (SB106) in 2019 that allowed the state to submit a Medicaid expansion proposal to CMS, but only for people earning up to 100% of the poverty level (as opposed to 138%, as called for in the ACA). As described above, CMS approved the partial expansion to take effect in mid-2021, but rejected the state’s request for full Medicaid expansion funding. Now that the Biden administration has indicated that the associated work requirement approval might be rescinded, the future of Georgia’s partial Medicaid expansion is uncertain.
Medicaid work requirements
Requiring Medicaid enrollees to be working (or volunteering, in school, in job training, etc.) for at least a certain number of hours per week is an idea that tends to be popular with Republican lawmakers. Most people who receive Medicaid benefits are either already working or would be exempt from work requirements (due to being disabled, taking care of a minor child, pregnant, etc.), but the myth of the “welfare queen” (or king) persists, and Medicaid work requirements are seen by some as a solution to a perceived problem.
The federal Centers for Medicare and Medicaid Services (CMS) has to approve a Medicaid work requirement before a state can implement it. The Obama administration did not allow any work requirements for Medicaid, but the Trump administration was much more open to the idea.
As of early 2020, twelve states had received federal approval for work requirements, and several others had pending waivers or were expected to submit waivers in the near future. But work requirements were only in effect in Utah and Michigan as of January 2020, and both have since been suspended (Utah’s as a result of the COVID-19 pandemic, and Michigan’s as a result of a court order). There continue to be no Medicaid work requirements in effect as of mid-2021, and the Biden administration has clearly communicated that they do not consider Medicaid work requirements to be in line with the mission of the Medicaid program.
Early in the COVID-19 pandemic, the US enacted the Families First Coronavirus Response Act in March 2020. Among many other things, the law addresses a wide range of insurance-related issues. One of them is a temporary increase in the portion of Medicaid costs that the federal government pays for each state — but that additional funding is contingent on the states not removing anyone from their Medicaid roles until the end of the COVID-19 emergency period — which is expected to last throughout 2021 — unless the person moves out of the state or voluntarily requests that their Medicaid coverage be terminated (the Georgetown University Health Policy Institute has a good summary of the Medicaid provisions in the law).
So for the time being, Medicaid work requirements are essentially a no-go, as they would cause a non-compliant enrollee’s Medicaid coverage to be involuntarily terminated. Shortly after the federal coronavirus relief law was enacted, Utah suspended its Medicaid work requirement, which was the only one in effect in the country at that point (Michigan’s had been overturned by a judge the month before).
Wisconsin had been working towards implementation a work requirement in early 2020, which would have been the first work requirement in a state that hasn’t expanded Medicaid. But amid the COVID pandemic, Wisconsin suspended the implementation of the work requirement.
A federal judge has overturned federally-approved Medicaid work requirements in Arkansas, Kentucky, New Hampshire, and Michigan, citing the fact that numerous people would lose coverage under the terms of the work requirements, and the government had done nothing to ameliorate that problem. The Trump administration and some of the affected states appealed the court ruling, and the Supreme Court had planned to hear the case. But the Biden administration clarified that they would not support an appeal of the court rulings that overturned the work requirements, and the Supreme Court pulled the case from its list of scheduled arguments in 2021.
In the rest of the states where Medicaid work requirements have been approved, they have either been overturned by a judge, paused by state administrators, or are not yet scheduled to take effect.
The work requirement in Arkansas was halted in 2019, New Hampshire had already delayed its program before it was overturned, and Kentucky’s new governor officially withdrew the work requirement proposal soon after taking office. Governors in Virginia and Maine have also paused or withdrawn the Medicaid work requirements in those states.
Medicaid work requirements in Arizona and Indiana have been postponed or suspended for the time being. And notably, the bipartisan Medicaid expansion legislation that was considered (but not enacted) in Kansas in 2020 did not include a work requirement (it called for a work referral program instead, which would have been less costly for the state to administer and would not have resulted in people losing their coverage).
The following is a summary of what’s happened in each of the states where work requirements have been approved or are pending federal approval (Keeping in mind that the Families First Coronavirus Response Act effectively prohibits Medicaid work requirements for now, and the fact that the Biden administration has notified all of these states that they are reconsidering work requirement approvals and may rescind them):
Work requirements for states that have expanded Medicaid:
Work requirements that were in effect in early 2020 but have since been suspended:
- Michigan (approved, effective January 2020, but overturned by a judge in March 2020) — 80 hours per month (Michigan legislation initially called for 29 hours per week of work/community engagement, but it was revised to 80 hours per month before the final bill passed). A federal judge overturned the state’s Medicaid work requirement in early March 2020, so residents are not currently required to comply with it.
- Utah (approved, effective January 2020, but suspended amid the COVID-19 outbreak in April 2020) — beneficiaries are exempt from the community engagement requirement as long as they’re working at least 30 hours per week. And there are numerous other exemptions for various populations. But people who weren’t exempt had to comply with the state’s community engagement requirements. This involved creating an account on jobs.utah.gov, completing an online evaluation and workshops, and applying for at least 48 jobs within a three-month period.
Medicaid expansion states where new governors withdrew pending work requirements:
- Maine (approved, but rejected by Gov. Mills soon after she took office) The 20-hour per-week work requirement could have taken effect as of July 2019, and was approved while Gov. LePage was still in office (and still blocking the Medicaid expansion ballot initiative that voters had approved the previous year). Mills implemented Medicaid expansion and withdrew the work requirement.
- Virginia — (withdrawn by Gov. Ralph Northam). Virginia enacted a budget in 2018 that called for Medicaid expansion starting in January 2019, but also directed the state to seek federal permission for a work requirement. The state submitted a waiver proposal in late 2018. But in late 2019, before the proposal had been approved by CMS, Gov. Ralph Northam formally delayed the work requirement portion of the waiver. When CMS approved the waiver later that month, they noted that the work requirement (along with a few other provisions) were not being approved at that point, at the state’s request.
- Kentucky (withdrawn by Gov. Andy Beshear) Kentucky’s work requirement was the first to be approved by CMS. It was to be effective July 2018, but a federal judge halted the implementation of the work requirement in late June; CMS reopened the comment period and ultimately reapproved the work requirement, with no substantial changes, with an April 2019 effective date. But it was once again overturned by the judge, so it never took effect. Gov. Beshear withdrew the former administration’s waiver shortly after taking office.
Expansion states where work requirements have been approved by CMS but are not yet in effect as of late 2020:
- Arkansas (CURRENTLY PAUSED AFTER JUDGE OVERTURNED THE WORK REQUIREMENT) approved, effective June 2018 for people age 30-49; people age 19-29 were expected to have to comply as of 2019. — 80 hours per month.
- Indiana (CURRENTLY PAUSED, AWAITING OUTCOME OF LAWSUIT) approved, phased in, starting in 2019: 5 hours per week initially, increasing to 20 hours per week.
- New Hampshire (CURRENTLY PAUSED AFTER JUDGE OVERTURNED THE WORK REQUIREMENT) approved, initially scheduled to take effect in April 2019, but delayed until September 2019 before being overturned by a judge — 100 hours per month.
- Arizona (POSTPONED UNTIL FURTHER NOTICE) — 80 hours per month for people age 19 to 49. Had been scheduled to take effect in some areas of the state in the fall of 2020, and roll out to other parts of the state in 2021 and 2022.
- Ohio (POSTPONED DUE TO COVID PANDEMIC) — 20 hours per week. Ohio initially planned to implement the work requirement as of January 2021, but has postponed it as a result of the COVID pandemic and the enhanced federal funding stipulation that prohibits states from terminating coverage during the health emergency.
- Nebraska (SCHEDULED TO TAKE EFFECT IN APRIL 2022) — Medicaid expansion took effect in October 2020, and the state’s Medicaid community engagement proposal (which was part of the Medicaid expansion plan) was approved later that same month (state officials had previously acknowledged that it wouldn’t be approved in time for the expansion start date). Nebraska’s 80-hour per month work requirement is different from most of the other states though: It’s intended to be a way for beneficiaries to obtain additional benefits, as opposed to a requirement for basic eligibility.
Medicaid expansion states with pending work requirement proposals:
- Idaho — submitted a work requirement proposal to CMS in September 2019. Medicaid expansion took effect in Idaho as of January 2020, but the work requirement waiver proposal was still pending federal approval as of late 2020. If approved, the work requirement would call for Medicaid expansion enrollees to work at least 20 hours per week.
- Montana — Medicaid expansion took effect in Montana in 2016, but the state is now seeking federal approval to add a work requirement. The waiver proposal was submitted to CMS in August 2019 and is pending approval. The state had initially planned to implement the requirement as of January 2020, but that’s been delayed (the federal review process can take many months, and the COVID pandemic would have caused further delay). If approved, the work requirement calls for participants to work at least 80 hours per month.
Lawmakers in Louisiana considered several work requirement bills in 2018, but none were enacted. Lawmakers in Pennsylvania passed Medicaid work requirement legislation in 2017 and again in 2018, but Governor Tom Wolf vetoed both bills.
Lawmakers in Alaska considered Medicaid work requirement legislation in 2019, but the measure did not advance to a vote.
Work requirements for states that have not expanded Medicaid:
Several states that have not expanded Medicaid are seeking federal permission to impose Medicaid work requirements, despite the fact that their Medicaid populations are comprised almost entirely of those who are disabled, elderly, or pregnant, as well as children.
The Trump Administration has begun granting work requirements in some of these states, although CMS Administrator, Seema Verma clarified in May 2018 that these states would have to clearly demonstrate how they plan to avoid situations in which people lose access to Medicaid as a result of the work requirement, and yet also do not have access to premium subsidies in the exchange.
Non-expansion states with approved Medicaid work requirements:
Two non-expansion states have been granted federal approval to implement Medicaid work requirements for their existing Medicaid populations:
- South Carolina (approved in late 2019, but not yet implemented) — 80 hours per week. The state has delayed implementation until after the COVID emergency period ends, but is asking the Biden administration to allow it to proceed after that (the Biden administration had previously notified the state that they were in the process of considering whether to withdraw approval for the work requirement).
- Wisconsin (approved, was slated to take effect in November 2019 was then delayed until sometime in 2020 and then indefinitely delayed as a result of the COVID pandemic) — 80 hours per month. A week after CMS approved Wisconsin’s waiver, voters elected Democrat Tony Evers to replace GOP Governor Scott Walker. Evers is opposed to the work requirement, but lawmakers in Wisconsin refused to repeal it. Note that although Wisconsin has not expanded Medicaid as called for in the ACA, there is no coverage gap in Wisconsin as people below the poverty level are eligible for Medicaid.
Non-expansion states seeking federal permission to impose a Medicaid work requirement:
Note that these states’ waiver proposals were all pending when the Biden administration took office. None are likely to be approved, given that the Biden administration has noted that work requirements are not in line with the overall mission of Medicaid (ensuring access to health care).
- Mississippi (pending CMS approval) — 20 hours per week
- South Dakota (pending CMS approval) — 80 hours per month
- North Carolina (pending CMS approval, but lawmakers would have to first approve the Carolina Cares legislation (or a similar bill), which calls for expanded Medicaid with a work requirement; North Carolina has not proposed a work requirement for the currently-eligible Medicaid population)
- Alabama (pending CMS approval) — 35 hours per week.
- Tennessee (pending CMS approval — 20 hours per week.
- Oklahoma (pending CMS approval — 80 hours per month. (Oklahoma will expand Medicaid by mid-2021 as a result of a ballot initiative that voters in the state passed in 2020.)
Kansas had also requested CMS approval for a work requirement of 20 or 30 hours per week, depending on circumstances. But that provision was later removed from the state’s Medicaid renewal proposal, and the waiver approval that was granted by CMS in December 2018 did not include a work requirement. And the bipartisan Medicaid expansion legislation that Kansas lawmakers considered in 2020 called for a work referral program instead of a work requirement.
Lawmakers in Missouri also considered legislation that called for an 80 hour per month work requirement, but the bill did not pass in the 2018 session. And voters in Missouri approved a ballot measure in 2020 that directs the state to expand Medicaid by mid-2021.
Medicaid and the COVID pandemic
As noted above in the section about work requirements, the Families First Coronavirus Response Act (FFCRA) essentially prevents states from making their eligibility standards any more strict during the COVID emergency period than they were as of the start of 2020.
Section 6008 of the FFCRA provides states with a 6.2 percentage point increase in their federal Medicaid matching funding for the duration of the COVID public health emergency period, as long as the state Medicaid program:
- keeps its eligibility standards no more restrictive than they were at the start of 2020,
- does not raise premiums above the levels they were at in January 2020,
- provides no-cost coverage for COVID testing and treatment,
- does not terminate enrollees’ coverage for the duration of the COVID emergency period, unless they move out of the state or request that their coverage be terminated.
CMS previously interpreted this last point to mean that in order to receive the increased federal Medicaid funding, “a state must keep beneficiaries enrolled in Medicaid, if they were enrolled on or after March 18, 2020, with the same amount, duration, and scope of benefits,” and that “states could not subject such beneficiaries to any increase in cost-sharing or beneficiary liability for institutional services or other long-term services and supports (LTSS) during this time period.”
This meant that a state could not terminate a beneficiary’s coverage (unless the beneficiary voluntarily disenrolled or moved out of the state). And if the state determined that the beneficiary’s circumstances had changed such that they should be moved to a different eligibility category with reduced benefits or increased cost-sharing, the state would not be able to transition the beneficiary to that new eligibility category until the COVID public health emergency ends.
But in November 2020, the Trump administration published an interim final rule to update earlier rulemaking related to the COVID pandemic. The new rules take effect immediately, but public comments were being accepted through January 4. (The November 2020 guidance is called an interim final rule with request for comments, or IFC.) The IFC addresses a wide range of topics, including a revision to how the administration had previously interpreted Section 6008 of the FFCRA.
In the IFC, the administration implemented a new approach, designed to give states more flexibility but also panned by critics as allowing states to reduce Medicaid benefits in the midst of a global health crisis. Under the IFC, states are still required to keep Medicaid beneficiaries enrolled in coverage unless they voluntarily disenroll or move out of state. But states are no longer required to maintain enrollees’ current specific benefits in order to continue to receive the enhanced federal funding.
The IFC attempts to reach a compromise that allows states to reduce benefits (while still maintaining Medicaid enrollment) but not so much that a “validly enrolled” Medicaid beneficiary would lose access to minimum essential coverage or to no-cost coverage for COVID testing and treatment (note that there is considerable controversy about the concept of “validly enrolled,” and that this provision could result in some people losing coverage who would not have lost coverage without this caveat in the IFC). Most types of Medicaid coverage are considered minimum essential coverage, but there are a few exceptions. Under the IFC, a person whose Medicaid eligibility circumstances change (eg, due to age, or length of time since a baby was born, etc.) could be moved to another eligibility category. But if their original Medicaid coverage was considered minimum essential coverage, they could only be moved to a category that also provides minimum essential coverage. And if their original category was not minimum essential coverage but did provide access to zero-cost COVID testing and treatment, they could only be moved to another category that also provides that benefit.
But the IFC also allows states to make “programmatic changes,” including changes to the medical necessity criteria, elimination of optional benefits such as adult dental and vision coverage, new limits on the number of covered visits for a particular service, or changes to cost-sharing levels (except for COVID testing and treatment, which have to continue to have zero cost-sharing).
The IFC does not change anything about the first requirement for the enhanced federal Medicaid funding, which is that a state cannot make its Medicaid eligibility standards any more restrictive than they were at the start of 2020. So as noted above, Medicaid work requirements would still prevent a state from receiving the additional federal funding.
Revising the IFC is among the various health care actions that the Biden administration could take, but they have not done so as of June 2021.
Other Medicaid proposals to watch
Several states have sought CMS approval to implement lifetime caps for Medicaid coverage, including Arizona, Kansas, Maine, Utah, and Wisconsin. But thus far, CMS has not approved this provision for any states. Arizona’s work requirement approval noted that CMS was rejecting the state’s proposal to cap eligibility at five years for people who were subject to, but not in compliance with, the work requirement.
The Trump administration also rejected Arkansas’ proposal to cap Medicaid eligibility at 100% of the poverty level, instead of 138%. The agency also rejected a similar proposal from Utah in 2019, and from Georgia in 2020. Massachusetts has a similar request that is pending CMS approval, although Massachusetts has already expanded Medicaid.
And no states have received approval for an asset test for Medicaid. Maine proposed an asset test as part of an 1115 waiver proposal, but that portion of the waiver was not approved.
Several states have received approval, however, to impose premiums on certain Medicaid populations, restrict retroactive eligibility, and require more eligibility redeterminations.
“Private option” Medicaid
Arkansas pioneered the “private option” approach to the state Medicaid expansion, under which the state uses Medicaid funds to purchase private health insurance in the individual market for Medicaid-eligible enrollees. Some other states followed suit to varying degrees over the coming years, but have since transitioned back to a more traditional approach (Medicaid fee-for-service or Medicaid managed care). Arkansas is the only state that still uses the private option approach.
New Hampshire enacted legislation in 2018 that directed the state to abandon the private approach to Medicaid expansion that was being used in the state at the time (buying policies in the exchange for people eligible for expanded Medicaid) and switch to a Medicaid managed care program instead. The state submitted a waiver amendment proposal to CMS in August 2018, and the transition took effect in 2019.
Iowa’s Medicaid expansion program initially used Medicaid funds to buy marketplace coverage for people with income above the poverty level, but the state switched to regular Medicaid managed care as of 2016.
Some states have also considered the possibility of seeking approval for a Medicaid buy-in program, under which people who aren’t eligible for Medicaid would be allowed to purchase Medicaid coverage. This is an excellent overview of the status of Medicaid buy-in legislation in various states.
Nevada lawmakers passed legislation to allow Medicaid buy-in during the 2017 legislative session, but the governor vetoed it. Lawmakers in Colorado, Maryland, and New Mexico considered legislation in 2018 that would direct the state to conduct a study on the feasibility and cost of a Medicaid buy-in program (ie, allowing people who aren’t eligible for Medicaid to purchase Medicaid coverage instead of private market coverage). Colorado lawmakers ultimately did not pass the bill, and neither did Maryland lawmakers. But New Mexico enacted legislation in early 2018 calling for a study on the costs and ramifications of a Medicaid buy-in program. Lawmakers in New Mexico considered SB405 in 2019 (which would have created a Medicaid buy-in program), but it did not pass.
Minnesota lawmakers considered, but did not pass, a bill in 2017 that would have allowed people to buy into MinnesotaCare, the state’s Basic Health Program (similar to Medicaid, but for people with slightly higher income). This issue was revisited in 2018 and DFLers still supported it in 2019, but it hasn’t gone anywhere yet.
Thus far, Medicaid buy-in has not gained much traction. But Democrats have been warming to the idea of a public option or single-payer system. (A public option program debuted in 2021 in Washington. Lawmakers in Colorado and Nevada are working on public option legislation during the 2021 session. But none of these states have taken a Medicaid buy-in option.)
History of Medicaid expansion
As noted at the start of this summary, Medicaid was a cornerstone of ACA lawmakers’ efforts to expand access to healthcare. The idea was that everyone with household incomes up to 133 percent of the federal poverty level (FPL) would be able to enroll in Medicaid.
People above that threshold – but whose incomes didn’t exceed 400 percent of FPL – would be eligible for premium tax credits in the exchanges to make their coverage affordable.
The idea was that people with income above 400 percent of the poverty level would be able to afford coverage without subsidies, but that has not proven to the case. Many Democratic lawmakers have called for the elimination of the income cap for subsidy eligibility, replacing it with the concept that nobody should pay more than a set percentage — generally in the range of 10 percent — of their income for a benchmark health plan, with subsidies as necessary to make this happen. (Regardless of income, people who get their insurance from an employer receive subsidies in the form of the employer’s contribution to their premiums — which are typically very substantial — and their premiums are pre-tax).
Because Medicaid expansion was expected to be a given in every state, the law was written so that premium subsidies in the exchange are not available to people with incomes below the poverty level. They were supposed to have access to Medicaid instead.
13 states still say ‘No’ to Medicaid expansion (Missouri may expand coverage in 2021, depending on the outcome of a court case)
Unfortunately for millions of uninsured Americans, in 2012 the Supreme Court ruled that states could not be penalized for opting out of Medicaid expansion. And 13 states have not yet expanded their programs, although that might drop to 12 if a judge rules that Missouri must expand Medicaid in 2021 in line with the ballot measure that the state’s voters passed in 2020. The court case for this is scheduled for June 2021, after GOP lawmakers in Missouri refused to allocate funding for the voter-approved expansion of Medicaid.
Until late 2015, there were still 22 states that had not expanded Medicaid, but Montana began enrolling people in their newly expanded Medicaid program in November 2015, for coverage effective January 2016, Alaska’s Medicaid expansion took effect in September 2015, Louisiana’s Medicaid expansion took effect in July 2016, and Virginia began enrolling people in expanded Medicaid as of November 2018, for coverage effective January 2019. Maine expanded Medicaid as soon as Governor Mills took office in early 2019. Utah and Idaho both implemented full Medicaid expansion as of 2020, and Nebraska‘s Medicaid expansion took effect in October 2020. Oklahoma’s Medicaid expansion takes effect July 1, 2021, with enrollment beginning June 1.
As a result of those 13 states refusal to accept federal funding to expand Medicaid, the Kaiser Family Foundation estimates there are 2.2 million people in the coverage gap across 12 of those states (although Wisconsin has not expanded Medicaid under the ACA, BadgerCare Medicaid is available for residents with incomes up to the poverty level, so there is no coverage gap in Wisconsin).
Being in the coverage gap means you have no realistic access to health insurance. These are people with incomes below the poverty level, so they are not eligible for subsidies in the exchange. But they are also not eligible for their state’s Medicaid program.
In many of the states that have not expanded Medicaid, low-income adults without dependent children are ineligible for Medicaid, regardless of how little they earn. For those who do have dependent children, the income limit for eligibility can be very low: In Alabama, parents with dependent children are only eligible for Medicaid if their income doesn’t exceed 13 percent of the poverty level. For a family of three, that’s only $231 per month (and yet, Alabama wants to impose a strong work requirement on those parents who are currently eligible for coverage).
More states easing into expansion
New Hampshire, Michigan, Indiana, Pennsylvania, Alaska, Montana, and Louisiana all expanded their Medicaid programs between 2014 and 2016. Expansion took effect in Virginia and Maine in 2019, in Utah, Idaho, and Nebraska in 2020, and in Oklahoma in 2021. It might also take effect in Missouri in 2021, depending on the outcome of the lawsuit over Missouri’s voter-approved ballot measure that calls for Medicaid expansion.
The 2018 election was pivotal for Medicaid, with three states passing ballot initiatives to expand Medicaid, and Kansas, Wisconsin, and Maine electing governors who are supportive of Medicaid expansion (Maine voters had already approved Medicaid expansion in the 2017 election, but it wasn’t implemented until early 2019, when the state’s new governor took office).
The first six states to implement Medicaid programs did so in 1966, although several states waited a full four years to do so. And Alaska and Arizona didn’t enact Medicaid until 1972 and 1982, respectively. Eventually, Medicaid was available in every state, but it certainly didn’t happen everywhere in the first year.
There’s big money involved in the Medicaid expansion decision for states. Under ACA rules, the federal government pays the vast majority of the cost of covering people who are newly eligible for Medicaid. Through the end of 2016, the federal government fully funded Medicaid expansion. The states started to pay a small fraction of the cost starting in 2017, eventually paying 10 percent by 2020. From there, the 90/10 split is permanent; the federal government will always pay 90 percent of the cost of covering the newly eligible population, assuming the ACA remains in place (which is not a given, due to the California v. Texas lawsuit, scheduled to be argued in front of the Supreme Court in November 2020).
The cost of NOT expanding Medicaid eligibility
Because the federal government funds nearly all of the cost of Medicaid expansion, the 14 states that haven’t yet taken action to expand Medicaid have been missing out on significant federal funding — more than $305 billion between 2013 and 2022.
(Indiana, Pennsylvania, Alaska, Montana, Louisiana, Virginia, Maine, Utah, Idaho, Nebraska, and Oklahoma have expanded their Medicaid programs since that report was produced in 2014, so they are no longer missing out on federal Medicaid expansion funding.)
Just five states – Florida, Texas, North Carolina, Georgia, and Tennessee – would have received nearly 60% of that funding (a total of $227.5 billion) if they had expanded Medicaid to cover their poorest residents starting in 2013. The good news is that although the federal government is no longer funding the full cost to expand Medicaid, they’ll always pay at least 90% of the cost, making the state Medicaid expansion a good deal for states regardless of when they implement it (in other words, for every dollar a state spends to cover its Medicaid expansion population, the federal government will kick in $9).
For residents of states that haven’t expanded Medicaid, their federal tax dollars are being used to pay for Medicaid expansion in other states, while none of the Medicaid expansion funds are coming back to their own states. From 2013 to 2022, $152 billion in federal taxes will be collected from residents in states not expanding Medicaid, and will be used to fund Medicaid expansion in other states.
The human toll of the Medicaid coverage gap
Of course, there’s more to Medicaid expansion than just money. Harold Pollack very clearly explains the human toll of the Medicaid coverage gap: Based on the 3,846,000 people who were expected to be in the coverage gap in January 2015, we can expect 4,633 of them to die in any given year because they don’t have health insurance.
(Pollack’s number is higher, because his article was written in May 2014. Since then, 12 additional states have expanded Medicaid, resulting in fewer people stuck in the coverage gap. Unfortunately, some of the states with the largest number of people in the coverage gap have steadfastly refused to accept federal funding to expand Medicaid.)
Public support for Medicaid expansion
Public support for Medicaid expansion is relatively strong, even in Conservative-leaning states: In Wyoming (considered the most Conservative state), 56 percent of the public are in favor of Medicaid expansion. But the Republican-led legislature in Wyoming has consistently rejected Medicaid expansion, despite Republican former Governor Matt Mead’s support for expansion.
Voters in Utah, Idaho, and Nebraska — all conservative-leaning states — approved Medicaid expansion ballot initiatives in the 2018 election. And the same thing happened in Missouri and Oklahoma in 2020.
In Texas – home to more than a quarter of those in the coverage gap nationwide – a board of 15 medical professionals appointed by then-Governor Rick Perry recommended in November 2014 that the state accept federal funding to expand Medicaid, noting that the uninsured rate in Texas was “unacceptable.” But no real progress towards Medicaid expansion has been made since then, and U.S. census data indicated that 18.4 percent of Texas residents were uninsured in 2019 – the highest rate in the country
There are several other states where the legislature or the governor – or both – are generally opposed to the ACA, but where Medicaid expansion has been actively considered, either by the governor or legislature or in negotiations with the federal government. These include Kansas, North Carolina, and Tennessee.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.